Let’s Hyperpronate!

There are two ways to treat a Nursemaid’s elbow (radial head subluxation) – supination/flexion or hyperpronation. I’ve done both. I’m a fan of hyperpronation, so, therefore, I’m highlighting a study that agrees with my practice pattern.

This systematic review covers 7 studies enrolling 701 patients, comparing the success rate and perceived pain of each technique. Trials were, generally and for some obvious reasons, limited in terms of blinding and outcome assessment. Pooled failure rate with hyperpronation 9.1% was while failure with supination /flexion was 27.3%. In studies reporting pain scores, subjective external rating of child pain during procedure also favored the hyperpronation group.

Use it!

This video demonstrates both techniques, although I’ve seen variations on hyperpronation both using extension and flexion.

“Effectiveness of reduction maneuvers in the treatment of nursemaid’s elbow: A systematic review and meta-analysis”
https://www.ncbi.nlm.nih.gov/pubmed/27836316

Death From Pills

Now that physicians can be convicted of murder for irresponsible opiate prescribing, it’s worth reviewing precisely how we’re fulfilling our felonious destiny.

This is a brief look at the prescription drug-related deaths in San Diego County for the year 2013.  These authors identified each patient death, performed a pharmacy query for all the medications prescribed in the year prior, and then compiled descriptive statistics regarding the providers and specialties involved.  The results are disturbing, yet unsurprising.

  • Primary care provided the bulk of prescriptions related to the 254 deaths, whether opiates, benzodiazepines, or sleep aids.
  • Regarding opiates, 190 patients amassed 2,350 prescriptions totaling 205,700 pills – over 1,000 per patient.
  • Emergency providers were not terribly over-represented, and provided among the fewest pills per prescription, at 22.9.
  • The sample sizes of many subspecialties were small, but the 22 orthopedists captured by this analysis provided an average 169 pills each refill.
  • “Doctor shoppers” constituted 28% of patients, but received 51% of the total prescriptions.  Various surgical specialties seemed to be their primary target.

As irritating as unnecessary antibiotic prescriptions and their ilk may be, this is far more gruesome and disappointing a spectacle.

“Who is prescribing controlled medications to patients who die from prescription drug abuse?”
http://www.ncbi.nlm.nih.gov/pubmed/26476578

A Mostly Uninformative Back Pain Trial in JAMA

There were almost 3 million visits to U.S. Emergency Departments last year for low back pain – and, yet, it is fair to say we manage these visits poorly.  Patients typically continue to have pain at discharge, at long-term follow-up, and we inject a vast number of opiates into circulation in the course of treatment.

This trial, appropriately, looks at a few of our most common prescriptions: scheduled NSAID (naprosyn), an anticholinergic smooth-muscle relaxant (cyclobenzaprine), and an opiate (oxycodone-acetaminophen).  Patients presenting to Montefiore hospital in the Bronx were randomized into three arms, and medications distributed in placebo-controlled, blinded fashion.

However, the primary outcome was not exactly what you might expect.  These authors used a questionnaire describing functional impairment, and used the change in impairment from enrollment to 1 week as their primary outcome.  This is an interesting choice as, while it doesn’t encounter some of the subjectiveness of pain scales, level of function is a technically surrogate outcome for pain relief.  Then, since it can be reasonably suggested the simple passage of time is the curative element in most cases of acute low back pain, it reasonable to expect such disability to regress to the mean, regardless of therapy, by one week.  I wonder if these authors did not inadvertently choose an outcome likely to show no difference.

And, that is precisely what they found.  At 1 week and – in another odd timeframe choice – 3 months.

However, that’s not the entirety of the story.  They measured many different outcomes, including adherence, utilization of the as-needed study medication, desire for same medication, days of return to work, and self-reported pain.  None of these secondary outcomes can be parsed reliably, but the general signal throughout is one of increased relief with the use of opiates.  It should be noted the authors’ conclusion is worded carefully – simply stating these data “do not support the use” of the therapies tested.  I am all for the avoidance of opiates, but the outcome measurement in this study probably obfuscates any potential benefit, and may rather mask their utility.

Lastly, these authors screened 2,588 patients with a complaint of low back pain in order to identify 390 meeting their inclusion criteria.  Radicular pain, traumatic pain, long-standing back pain, and elderly patients were all excluded – and, clearly, make up the bulk of visits to the Emergency Department.  These data apply to only a very small subset of patients, and they were enrolled at a single center.  The generalizability of their findings is not ideal.

It’s not a sexy topic, but its prevalence certainly makes it an important one.  If a fraction of the hundreds of millions of dollars devoted to the development of me-too blockbuster copycat drugs were devoted to such common issues, we would have far better data to guide the bulk of our practice.  I love that these authors did this trial – I just wish their measurements and timeframes differed.

“Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial”
http://jama.jamanetwork.com/article.aspx?articleid=2463257

Sedation May Not Always Be the Answer in Shoulder Reduction

A guest post by Dr. Andrew Kirkpatrick, an Emergency Medicine resident at the University of Texas Medical School at Houston.

What happens when you combine Ultrasound guided nerve blocks and shoulder reduction?  In the hands of experienced operators, not surprisingly, great things!

This is a randomized control trial of 41 patients out of Turkey that compared shoulder reduction utilizing procedural sedation versus an ultrasound guided suprascapular nerve block.  Using the modified Kocher method for reduction, the authors found that the nerve block leads to a statistically significant decrease in pain quantified by a Visual Analog Score.  There was also non-significant trend toward first attempt success using the Ultrasound guided nerve block, which may have been significant if the authors had bothered to calculate the appropriate sample size.  No side effects were noted in the group receiving regional anesthesia, while the sedation group predictably suffered nausea/vomiting in 15%, hypoxia in 10%, and agitation in 15%.  Time to discharge in the nerve block group was 100 minutes less than the procedural sedation group, a finding which reached statistical significance.   Lastly there was no significant difference in patient or physician satisfaction between the two groups, although trends in both cases favored the nerve block group.

Despite all of its short-comings – including small sample size, no blinding, and no clear primary outcome – the paper makes a case for using a suprascapular block to avoid the risks associated with procedural sedation for the reduction of this common dislocation.  The authors show shoulder reductions can be done in the Emergency Department without the use of procedural sedation.  True, there are some patients that cannot tolerate shoulder reduction without being fully disassociated from the event, but in the appropriately selected patient, the technique outlined in this article could decrease patient discomfort and decrease the risk to the patient undergoing shoulder reduction all without starting an IV.  In the world of emergency medicine where we are pressured to “treat and street” patients as quickly as possible while attempting to minimize risk to the patient, the ultrasound guided suprascapular nerve block seems like a great addition to the shoulder reduction armamentarium.

“A Comparison of Suprascapular Nerve Block and Procedural Sedation Analgesia in Shoulder Dislocation Reduction”
http://dx.doi.org/10.1016/j.ajem.2014.02.014

Unicycles, Not All Fun And Games?

Finally a study on Unicycles! According to Dr. Marvin Wang, the author of the recently published article “Unicycle Injuries In the United States”, his chart review of the National Electronic Injury Surveillance System (NEISS) is the entirety of the world’s literature on unicycle injuries. To my utter disappointment there were zero cases of falls from a tight rope or burns from a mishandled flaming juggling pin. Even the author himself observes that unicycles, once exclusively ridden by professional “circus folk” and acrobats, have now become primarily an amateur endeavor.
Ironically the same inherent mechanics and “sense of danger” that made the unicycle a popular circus act, makes it far safer than its two-wheeled cousin when used by the general public. Because of its single wheel, riders are far less capable of attaining high speeds and it is therefore infrequently used as a functional means of transportation. Given this lack of functional utility, riders of unicycles seem to have escaped the more serious types of cycle accidents such as high-speed crashes and collisions with motor vehicles. Upon review of the 85 cases of documented unicycle injuries found in the NEISS database from 1991 to 2010, the author extrapolates that 168 people a year visit the emergency department for unicycle related injuries in the United States. The most common injuries acquired were extremity fractures, sprains and strains. Very few head and neck injuries occurred, and the majority of these were scraps and abrasions.
The biggest weakness of this study is that we are unable to determine a denominator. Since we do not know what percentage of the US population at any time are riding unicycles, we are unable to quantify the risk of riding such a contraption. It may be that only a small percentage of riders will sustain an injury that requires an ED visit. Conversely it is possible that the risk is much higher. If you do decide to mount one of these single wheeled cycles you may be taking your life, or at least your limb into your own hands…
“Unicycle Injuries In the United States”
www.ncbi.nlm.nih.gov/pubmed/23871477
For more nihilism, emergency medicine and the art of doing nothing see emnerd.com and @CaptainBasilEM

Unicycles, Not All Fun And Games?

Finally a study on Unicycles! According to Dr. Marvin Wang, the author of the recently published article “Unicycle Injuries In the United States”, his chart review of the National Electronic Injury Surveillance System (NEISS) is the entirety of the world’s literature on unicycle injuries. To my utter disappointment there were zero cases of falls from a tight rope or burns from a mishandled flaming juggling pin. Even the author himself observes that unicycles, once exclusively ridden by professional “circus folk” and acrobats, have now become primarily an amateur endeavor.
Ironically the same inherent mechanics and “sense of danger” that made the unicycle a popular circus act, makes it far safer than its two-wheeled cousin when used by the general public. Because of its single wheel, riders are far less capable of attaining high speeds and it is therefore infrequently used as a functional means of transportation. Given this lack of functional utility, riders of unicycles seem to have escaped the more serious types of cycle accidents such as high-speed crashes and collisions with motor vehicles. Upon review of the 85 cases of documented unicycle injuries found in the NEISS database from 1991 to 2010, the author extrapolates that 168 people a year visit the emergency department for unicycle related injuries in the United States. The most common injuries acquired were extremity fractures, sprains and strains. Very few head and neck injuries occurred, and the majority of these were scraps and abrasions.
The biggest weakness of this study is that we are unable to determine a denominator. Since we do not know what percentage of the US population at any time are riding unicycles, we are unable to quantify the risk of riding such a contraption. It may be that only a small percentage of riders will sustain an injury that requires an ED visit. Conversely it is possible that the risk is much higher. If you do decide to mount one of these single wheeled cycles you may be taking your life, or at least your limb into your own hands…
“Unicycle Injuries In the United States”
www.ncbi.nlm.nih.gov/pubmed/23871477
For more nihilism, emergency medicine and the art of doing nothing see emnerd.com and @CaptainBasilEM

The Trauma Log Roll is Dead

Among unproven interventions, back-boarding, cervical collars, and log-rolling have been part of the dogma of trauma since Alfred Nobel invented the electric slide.  We’ve finally started to put an end to uncomfortable and unwarranted back-boarding, we’ve re-designed cervical collars, and this article takes on log-rolling.  The assertion of these authors is clinical examination of an otherwise alert major trauma patient is unreliable, does not obviate imaging, and may thereby be omitted from the initial secondary survey.

Unfortunately, this is a very specific, limited, retrospective registry review.  Only patients from the trauma registry at the Alfred Hospital were included: major trauma (ISS >15) and admitted for 24 hours, or isolated thoracolumbar injuries requiring 72 hours of hospitalization.  This identified 1,161 patients with thoracolumbar fractures, and these authors further pared it down to 538 who were GCS >15 as their proxy for potentially reliable examination.  How many of these alert, appropriate trauma patients with thoracolumbar fractures complained of pain on log-roll and spinal palpation?

60.3%.

So, yes, if the clinical examination is only 60.3% sensitive for significant thoracolumbar fractures, then we ought to stop bothering to log-roll our patients.  But, generalizing the evidence from this retrospective review in a highly selected population is grossly irresponsible.  It is reasonable, as the accompanying letter states, if the decision has already been made in a major trauma to progress to full-body computed tomography – a test more sensitive and specific for spinal fractures than clinical examination – log-roll and complete physical examination may be deferred.  The theoretical risks to log-roll – lack of true thoracolumbar stability, possibility of disturbing internal hemostasis – if there is no benefit, are appropriate considerations if physical examination does not change clinical evaluation.  It is, however, excessive to universally posit, as the letter authors do, “Log-rolling a blunt major trauma patient is inappropriate in the primary survey.”

“Can initial clinical assessment exclude thoracolumbar vertebral injury?”
www.ncbi.nlm.nih.gov/pubmed/22915226‎

“Log-rolling a blunt major trauma patient is inappropriate in the primary survey”
www.ncbi.nlm.nih.gov/pubmed/24136122

Ultrasound – For Long Bone Fracture

I have to say, I’m a little confused by all the new SonoSite television ads – direct-to-consumer marketing for sports medicine ultrasonography?  Or for zero-complication central line placement?  Weird.

But, I digress.  A little.  This is a pediatric study of lightly trained ultrasonographers with varying levels of expertise using ultrasound to diagnose long-bone fractures.  They performed 98 ultrasound examinations that were followed up by plain radiography, and they picked up 41 of the 43 fractures present, with 8 false positives:  95% sensitivity and 85% specificity.  Six required reduction, all of which were identified as meeting criteria for reduction on ultrasound – as well as one additional false positive from a distal radius fracture.


As a feasibility study, it’s a nice little pilot.  As a practice-changing strategy, it needs larger sample sizes and external validity.  However, it does seem as though it will soon become reasonable to use bedside ultrasound to quickly rule-out fracture in patients with a low pre-test probability, while plain radiography will continue to play a role in advanced orthopedics management.


“Emergency Ultrasound in the Detection of Pediatric Long-Bone Fractures”
www.ncbi.nlm.nih.gov/pubmed/23114237

Unnecessary Post-Reduction X-Rays?

Falling into the “well, duh” sort of category that cuts through the dogmatic haze, this article examines the ordering of post-reduction radiographs in the Emergency Department.

Specifically, this group of orthopedists from New York City looks at X-ray utilization and length-of-stay after consultation and management of minimally displaced, minimally angulated extremity fractures.  They note that, of 342 fractures meeting study criteria, 204 of them subsequently received post-splinting radiography.  They note that none of the patients receiving post-reduction radiography had any change in alignment or change in splint application, and this practice resulted in significantly longer ED length-of-stay.

This leads them to their conclusion that minimally displaced, minimally angulated extremity fractures that do not receive manipulation when splinting should not be re-imaged after splint application.  And, this seems like a fairly reasonable conclusion.  It’s retrospective, the outcomes are surrogates for patient oriented-outcomes, etc., and it would be reasonable to re-evaluate this conclusion in a prospective trial –   but if your practice is already to not routinely re-image, this supports continuing your entirely reasonable clinical decision-making.

“Post-Splinting Radiographs of Minimally Displaced Fractures: Good Medicine or Medicolegal Protection?”
http://jbjs.org/article.aspx?articleid=1356145

C-Collars Cannot Stabilize Unstable Injuries

This is another cautionary anatomic study that demonstrates cervical collars are not adequate immobilization devices – except in patients who already do not need them.

This is a cadaveric spinal immobilization study in which C5/C6 instability was induced, and the Ambu extrication collar, the Aspen collar, and no collar were evaluated for range of bending and rotation during a bed transfer simulation.

The results are pretty straightforward.  Before the instability was induced, patients had minimal neck movement, whether immobilized or not.  After instability was induced, the patients all had significant bending and rotation – nearly the same for the patients in the collars as in no collar at all.

This is consistent with the small amount of prior work done in actual unstable spines; most of the cervical collar data is in healthy volunteers.  The limitations of a cervical collar should be recognized, and patients should have their cervical spine evaluated and cleared or intervened on immediately.

“Cervical collars are insufficient for immobilizing an unstable cervical spine injury.”
www.ncbi.nlm.nih.gov/pubmed/21397431